Pre- Medical Appointment Questionnaire Pet NameClient NameDate Date Format: MM slash DD slash YYYY Reason for visit:1. What are the symptoms you are concerned about?2. When did they start?3. Is your pet in pain? What are they doing that tells you they hurt?4. Has this happened before?5. When did your pet last eat normally?6. What food is your pet currently eating?7. When did your pet last urinate?8. When did your pet have it’s last normal BM?9. Are they loose, watery, bloody?10. Has your pet vomited? If yes, how often?YesNoIf yes, how often?11. What medications if any is your pet currently on? Any supplements?12. What flea/tick products do you use?Client questions:1. Have you or anyone in your household had COVID19? If so, when?YesNoIf so, when?2. Have you or anyone in your household had any respiratory illness or other symptoms like loss of taste or smell in the past 2 weeks?3. What is the best phone number to reach you at?Is there anything else you’d like us to be aware of regarding your pet or yourself?
